Case 12780 Cervical spine schwannoma

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shows extradural extension to the left neural foramina at C1-C2 level, and ... spinal canal and para-spinal region causing widening of the neural foramina and ...

Case 12780 Cervical spine schwannoma Dr Neeraj Jain, Dr Lalit Garg, Dr Sachin Agrawal, Dr Vandana Goel, Dr Sunil Kumar Puri G B Pant Hospital, Radiology 110002 New Delhi, India; Email:[email protected] G B Pant Hospital, New Delhi Section: Neuroradiology Published: 2015, Jun. 2 Patient: 29 year(s), male

Clinical History Left-sided limb weakness progressing slowly for 3 months; no history of fever or trauma was present.

Imaging Findings MRI cervical spine shows the presence of a well-circumscribed, lobulated mass lesion in the left side intradural extramedullary compartment of the cervical spine at C1-C2 level. The mass lesion shows extradural extension to the left neural foramina at C1-C2 level, and protrudes both into the spinal canal and para-spinal region causing widening of the neural foramina and compression of the spinal cord. It shows heterogeneous hypointense signal on T1W images and hyperintense signal on T2W and STIR images with presence of T2W bright signal intensity area and fluid-fluid level suggestive of necrosis and intra-lesional haemorrhage.

Discussion Schwannoma is a slowly enlarging tumour, arising from nerve sheaths. It is the most common

extra-medullary intradural tumour of the spine. Cervical and lumber spines are the most common sites of origin. The majority of schwannomas are solitary neoplasms; however, multiple lesions are seen in patients with neurofibromatosis type 2. Pain, weakness and symptoms of radiculopathy/myelopathy are the most common mode of presentation. On CT they appear as well-circumscribed oval, rounded or dumbbell-shaped lesions, are seen iso to hypodense on non-contrast studies and demonstrate heterogeneous contrast enhancement. They are frequently associated with bony remodelling and may show presence of calcification and cystic necrosis. In the spine they are commonly located in the extra-medullary space and extend along the spinal cord and/or protrude from neural foramina into the para-vertebra region appearing as dumbbell-shaped lesions. MRI shows iso to hypointense signal on T1 and heterogeneous hyperintense signal on T2/STIR with internal cystic necrosis and haemorrhagic areas. Post-contrast study shows moderate to strong enhancement with non-enhancing necrotic areas in larger lesions [1]. Schwannomas are difficult to differentiate from neurofibroma. In general, schwannomas appear as rounded/dumbbell-shaped mass lesions with associated spinal canal / neural foramina widening, bony remodelling and may protrude out of the neural foramina. They are frequently associated with haemorrhage, necrosis and cystic degeneration [2] and these finding are rare in neurofibroma. Meningioma is another close differential diagnosis that in contrast to schwannoma shows broad-based dural attachment; appears iso-hypointense on T2 and shows homogeneous strong enhancement.

Final Diagnosis Spinal schwannoma

Differential Diagnosis List Neurofibroma, Meningioma

Figures Figure 1 T2 axial

T2 axial image: A well-circumscribed, lobulated extradural mass lesion in the left neural foramina, protruding into the spinal canal with indentation on the spinal cord, heterogeneous hyperintense signal with central necrosis. © Department od Radiodiagnosis, G B Pant Hospital, New Delhi

Area of Interest: Neuroradiology spine; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia; Figure 2 T1 axial

T1 axial image: hypointense signal © Department of Radiodiagnosis, G B Pant Hospital, New Delhi

Area of Interest: Neuroradiology spine; Imaging Technique: MR;

Procedure: Diagnostic procedure; Special Focus: Neoplasia; Figure 3 STIR coronal

STIR coronal image: A well circumscribed, lobulated extradural mass lesion with hyperintense signal in left neural foramina and spinal canal at C1-C2 level, causing spinal cord compression. © Department of Radiodiagnosis, G B Pant Hospital, New Delhi

Area of Interest: Neuroradiology spine; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia; Figure 4 T2 sagittal

T2 sagittal image: Shows heterogeneous hyperintense signal with fluid-fluid level. © Department of Radiodiagnosis, G B Pant Hospital, New Delhi

Area of Interest: Neuroradiology spine; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

References [1] Abul-Kasim K, et al. (2008) Intradural spinal tumors: current classification and MRI features. Neuroradiology 50 (4): 301-14. [2] Grossman RI, Yousem DM (2003) Neuroradiology The requisites. Mosby Inc.

Citation Dr Neeraj Jain, Dr Lalit Garg, Dr Sachin Agrawal, Dr Vandana Goel, Dr Sunil Kumar Puri G B Pant Hospital, Radiology 110002 New Delhi, India; Email:[email protected] (2015, Jun. 2) Cervical spine schwannoma {Online} URL: http://www.eurorad.org/case.php?id=12780

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